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-,;"-p ONSITE WAST' 'CATER TREATMENT SYSTF" PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPV16MENT 304 E WEBER AVEC./e'FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS ICA s� cv:te -12%0 -. CITY/ZIP 4 %i •� � CROSS STREET -+�"*5-�- ��- APN �-1'l `� d- 04 \ PARCEL SIZE P4 'k '"s v OWNER NAME �Z_ \ l✓�^�-^4-R- -- PHONE OWNER ADDRESS r3�Y7 O'HL'`�` (Y �',a - rt. ' CITY/STATE/ZIP C' r [C.'li• 4152-or CONTRACTOR �..�r� `^��`�^T �+-�- � rhe`- ��PHONE /p9.a•-a'O pj�j CONTRACTOR ADDRESS 9-1yc) �b'n1�� - CITY/STATE/ZIP �C � LICENSE ❑C42 ❑C-36 OTHER C-'1-( NUMBER 629-1%09 EXPIRATION DATE �e'30• S WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDIION ❑ ENGINEER —DESIGNED/ALTERNATIVE ❑ REPLACEMENT DESTRUCFION'2s?_ INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL R FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES R DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE fl ❑ FILTER BED WIDTH ft LENGTH ft DEPTH R DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft - DISTANCE TO NEAREST WELL R FOUNDATION It PROPERTY LINE ft ❑ SUMPS WIDTH R LENGTH R DEPTH ft t✓ DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE R ❑ DISPOSAL PONDS WIDTH R LENGTH R DEPTH R DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS WIDTH fl LENGTH ft DEPTH ft = DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. MINIMUM 24 HOUR ADVANCE NOT] E REQUIRED FOR INSPECTIONS-PLE E CALL(209)953-7697 SIGNED v1�, �- V� TITLE � DATE 1 9,11 I , 01 I S c N p T D -- - __-DEPARTMENT USE ONLY Application Acce Y Date ?G ` Area rZ.j Employee ID# Cab tp- Final IDspectio By 1� Dat ❑ SPECIAL PERMIT-Approved by Character of Sm o Depth oL Ft: Pit/Sump Soil Character: COMMENTS ,A�e rrv. .�1,P T-S - a �— �� .�%r✓J� r P SC Received Chec Amount Permit/ Code INPD 8 aash Remitted Date Service Re uest# Invoice# Permit ID# � Jf2.al Ci75 D 7 �9L'J 5 ° 42-0I-001 ONSITE WASTEWATER PERMIT 122/02